Anxiety Questionnaire

Please answer the following questions. For multiple choice questions where only one answer is required, select the answer that describes what happens most often. If you have trouble selecting just one answer, please narrow it down to a couple of possible answers, and then select the one that applies to you the most or most often.

For questions where multiple answers are acceptable, please check as many as apply to your situation.

1. Did you experience any of the following physical symptoms of anxiety in the last thirty days? (check as many as apply)

Pounding heart

Sweating

Trembling or Shaking

Shortness of breath

Nausea or vomiting

Chest pain or discomfort

Trembling hands

Feeling lightheaded or faint

Chills or hot flashes

Feeling dizzy or unsteady

Numbness or tingling sensations

Feeling of chocking or throat closing

Feeling shaky or wobbly

2. Did you experience any of the following mental/emotional symptoms of anxiety in the last thirty days? (check as many as apply)